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Treatment of Vertigo

RANDY SWARTZ, M.D., University of California, San Diego, School of Medicine, La Jolla, California
PAXTON LONGWELL, M.D., Corpus Christi, Texas

Vertigo is the illusion of motion, usually rotational motion. As patients age, vertigo becomes
an increasingly common presenting complaint. The most common causes of this condition are
benign paroxysmal positional vertigo, acute vestibular neuronitis or labyrinthitis, Ménière’s dis-
ease, migraine, and anxiety disorders. Less common causes include vertebrobasilar ischemia and
retrocochlear tumors. The distinction between peripheral and central vertigo usually can be made
clinically and guides management decisions. Most patients with vertigo do not require extensive
diagnostic testing and can be treated in the primary care setting. Benign paroxysmal positional
vertigo usually improves with a canalith repositioning procedure. Acute vestibular neuronitis or
labyrinthitis improves with initial stabilizing measures and a vestibular suppressant medication,
followed by vestibular rehabilitation exercises. Ménière’s disease often responds to the combination
of a low-salt diet and diuretics. Vertiginous migraine headaches generally improve with dietary
changes, a tricyclic antidepressant, and a beta blocker or calcium channel blocker. Vertigo associ-
ated with anxiety usually responds to a selective serotonin reuptake inhibitor. (Am Fam Physician
2005;71:1115-22, 1129-30. Copyright© 2005 American Academy of Family Physicians.)

V
Patient information: ertigo, a type of dizziness, is the can help narrow the differential diagnosis

A handout on vertigo, illusion of motion, usually rota- (Table 1).1 Psychiatric disorders, motion sick-
written by the authors of
this article, is provided on tional motion. Associated symp- ness, serous otitis media, cerumen impac-
page 1129. toms include nausea, emesis, and tion, herpes zoster, and seizure disorders also
See page 1046 for
diaphoresis. Vertigo should be distinguished can present with dizziness.
strength-of- from other types of dizziness, such as imbal- The physical examination should include
recommendations labels. ance (dysequilibrium) and lightheadedness measurements of orthostatic vital signs and
(presyncope). Most cases of vertigo can be an otoscopic examination. The neurologic
diagnosed clinically and managed in the examination should include the Dix-Hallpike
primary care setting. maneuver to differentiate peripheral from
central vertigo2,3 (Figure 1 and Table 23,4).
Vestibular Function and Vertigo No laboratory testing is absolutely indi-
Vertigo results from acute unilateral vestib- cated in the work-up of patients with ver-
ular lesions that can be peripheral (labyrinth tigo. If hearing loss is suspected, complete
or vestibular nerve) or central (brainstem or audiometric testing can help distinguish
cerebellum). In contrast, tumors and oto- vestibular pathology from retrocochlear
toxic medications produce slowly progres- pathology (e.g., acoustic neuroma).
sive unilateral or bilateral lesions. Lesions Brain imaging is warranted if a tumor or
that progress slowly or processes that affect stroke is suspected. The American College
both vestibular apparatuses equally usually of Radiology5 recommends magnetic reso-
do not result in vertigo. nance imaging with contrast medium when
a patient presents with acute vertigo and
Diagnosis of Vertigo sensorineural hearing loss. Magnetic reso-
In patients with vertigo, Because vertigo can have mul- nance angiography can be used to evaluate
the neurologic examina- tiple concurrent causes (espe- the vertebrobasilar circulation.
tion should include the cially in older patients), a
Dix-Hallpike maneuver to specific diagnosis can be elu- General Treatment Principles
differentiate peripheral sive. The duration of vertiginous MEDICATIONS
from central vertigo. episodes and the presence or Medications are most useful for treating
absence of auditory symptoms acute vertigo that lasts a few hours to several

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Strength of Recommendations

Key clinical recommendation Label References

The canalith repositioning procedure (Epley maneuver) is recommended in patients A 18, 19, 20
with benign paroxysmal positional vertigo.
The modified Epley maneuver also is effective in patients with benign paroxysmal positional vertigo. B 16
Vestibular suppressant medication is recommended for symptom relief in patients C 6, 7, 8
with acute vestibular neuronitis.
Vestibular exercises are recommended for more rapid and complete vestibular compensation in B 14
patients with acute vestibular neuronitis.
Treatment with a low-salt diet and diuretics is recommended for patients with Ménière’s disease B 23, 24, 25
and vertigo.
Effective treatments for vertiginous migraine include migraine prophylaxis (e.g., tricyclic antidepressants, B 13, 30, 31, 32
beta blockers, calcium channel blockers), migraine-abortive medications (e.g., sumatriptan [Imitrex]),
and vestibular rehabilitation exercises.
Selective serotonin reuptake inhibitors can relieve vertigo in patients with anxiety disorders. Because B 34
of side effects, slow titration is recommended.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented
evidence, usual practice, opinion, or case series. See page 1046 for more information.

days (Table 3).6,7 They have limited benefit in patients and the frequently concurrent nausea and emesis. These
with benign paroxysmal positional vertigo, because the medications exhibit various combinations of acetylcho-
vertiginous episodes usually last less than one minute. line, dopamine, and histamine receptor antagonism. The
Vertigo lasting more than a few days is suggestive of per- American Gastroenterological Association recommends
manent vestibular injury (e.g., stroke), and medications anticholinergics and antihistamines for the treatment of
should be stopped to allow the brain to adapt to new nausea associated with vertigo or motion sickness.8
vestibular input. Gamma-aminobutyric acid (GABA) is an inhibitory
A wide variety of medications are used to treat vertigo neurotransmitter in the vestibular system.6 Benzodiaz-

TABLE 1
Differential Diagnosis of Vertigo

Duration of Auditory Peripheral or central


Disorder episodes symptoms Prevalence vertigo

Benign paroxysmal positional vertigo Seconds No Common Peripheral


Perilymphatic fistula (head trauma, barotrauma) Seconds Yes Uncommon Peripheral
Vascular ischemia: transient ischemic attack Seconds to hours Usually not Uncommon Central or peripheral*
Ménière’s disease Hours Yes Common Peripheral
Syphilis Hours Yes Uncommon Peripheral
Vertiginous migraine Hours No Common Central
Labyrinthine concussion Days Yes Uncommon Peripheral
Labyrinthitis Days Yes Common Peripheral
Vascular ischemia: stroke Days Usually not Uncommon Central or peripheral*
Vestibular neuronitis Days No Common Peripheral
Anxiety disorder Variable Usually not Common Unspecified
Acoustic neuroma Months Yes Uncommon Peripheral
Cerebellar degeneration Months No Uncommon Central
Cerebellar tumor Months No Uncommon Central
Multiple sclerosis Months No Uncommon Central
Vestibular ototoxicity Months Yes Uncommon Peripheral

*—Vertigo can be caused by vascular ischemia in the central vertebrobasilar circulation or the peripheral circulation to the vestibular nerve and labyrinth.1

1116 American Family Physician www.aafp.org/afp Volume 71, Number 6 ◆ March 15, 2005
Vertigo
TABLE 2
Clues to Distinguish Between Peripheral and Central Vertigo

Clues Peripheral vertigo Central vertigo

Findings on Dix-Hallpike maneuver


Latency of symptoms and nystagmus 2 to 40 seconds None
Severity of vertigo Severe Mild
Duration of nystagmus Usually less than 1 minute Usually more than 1 minute
Fatigability* Yes No
Habituation† Yes No
Other findings
Postural instability Able to walk; unidirectional instability Falls while walking; severe instability
Hearing loss or tinnitus Can be present Usually absent
Other neurologic symptoms Absent Usually present

*—Response remits spontaneously as position is maintained.


†—Attenuation of response as position repeatedly is assumed.
Information from references 3 and 4.

epines enhance the action of GABA in the central ner- alternative visual and proprioceptive cues to maintain
vous system (CNS) and are effective in relieving vertigo balance and gait. It is necessary for a patient to reexperi-
and anxiety. ence vertigo so that the brain can adapt to a new baseline
Older patients are at particular risk for side effects of vestibular function. After acute stabilization of the
of vestibular suppressant medications (e.g., sedation, patient with vertigo, use of vestibular suppressant medi-
increased risk of falls, urinary retention). These patients cations should be minimized to facilitate the brain’s
also are more likely to experience drug interactions adaptation to new vestibular input.
(i.e., additive effects with other CNS depressants). A randomized, controlled trial (RCT)11 of 143 primary
care patients with dizziness and vertigo showed that
VESTIBULAR REHABILITATION EXERCISES vestibular rehabilitation exercises improved nystagmus,
Vestibular rehabilitation exercises commonly are postural control, movement-provoked dizziness, and
included in the treatment of vertigo9,10 (see patient infor- subjective indexes of symptoms and distress. Another
mation handout). These exercises train the brain to use RCT12 evaluated the effectiveness of home vestibular

45°

ILLUSTRATIONS BY MARCIA HARTSOCK

A. B.
Figure 1. Dix-Hallpike maneuver (used to diagnose benign paroxysmal positional vertigo). This test consists of a series
of two maneuvers: With the patient sitting on the examination table, facing forward, eyes open, the physician turns
the patient’s head 45 degrees to the right (A). The physician supports the patient’s head as the patient lies back quickly
from a sitting to supine position, ending with the head hanging 20 degrees off the end of the examination table. The
patient remains in this position for 30 seconds (B). Then the patient returns to the upright position and is observed for
30 seconds. Next, the maneuver is repeated with the patient’s head turned to the left. A positive test is indicated if any
of these maneuvers provide vertigo with or without nystagmus.

March 15, 2005 ◆ Volume 71, Number 6 www.aafp.org/afp American Family Physician 1117
TABLE 3
Medications Commonly Used In Patients with Acute Vertigo and Associated Nausea and Emesis

Medication Dosage Sedation Antiemesis Pregnancy category

Meclizine* (Antivert) 12.5 to 50 mg orally every 4 to 8 hours ++ + B


Dimenhydrinate* 25 to 100 mg orally, IM, or IV every 4 to 8 hours + ++ B
(Dramamine)
Diazepam (Valium) 2 to 10 mg orally or IV every 4 to 8 hours ++ + D
Lorazepam (Ativan) 0.5 to 2 mg orally, IM, or IV every 4 to 8 hours ++ + D
Metoclopramide 5 to 10 mg orally every 6 hours + +++ B
(Reglan) 5 to 10 mg by slow IV every 6 hours
Prochlorperazine 5 to 10 mg orally or IM every 6 to 8 hours + +++ C
(Compazine) 25 mg rectally every 12 hours
5 to 10 mg by slow IV over 2 minutes
Promethazine 12.5 to 25 mg orally, IM, or rectally every +++ ++ C
(Phenergan) 4 to 12 hours

*—Available over the counter.


+ = mild; ++ = moderate; +++ = prominent; IM = intramuscular; IV = intravenous.
Information from references 6 and 7.

rehabilitation in patients with chronic vertigo with a measure is not universally recommended. Contraindica-
peripheral vestibular etiology. This trial12 showed a sig- tions to canalith repositioning procedures include severe
nificant reduction of vertigo and an increase in the abil- carotid stenosis, unstable heart disease, and severe neck
ity to perform activities of daily living independently. disease, such as cervical spondylosis with myelopathy or
A retrospective case series13 assessed the efficacy of advanced rheumatoid arthritis.17
physical therapy in patients who had vestibular and bal- Canalith repositioning has been found to be effective
ance disorders with or without a history of migraine. in patients with benign paroxysmal positional vertigo.
Both groups showed significant alleviation of dizziness The initial report15 on the Epley maneuver indicated
and improvement of balance and gait. Vestibular exer- an 80 percent success rate after a single treatment and
cises also have been shown to improve postural control a 100 percent success rate with repeated treatments.
during the first month after acute unilateral vestibular Two subsequent RCTs18,19 reported success rates of 50 to
lesions resulting from vestibular neuronitis.14 90 percent. A Cochrane systematic review20 concluded
that the Epley maneuver is a safe treatment that is likely
Treatment of Specific Disorders to result in improvement of symptoms and conversion
BENIGN PAROXYSMAL POSITIONAL VERTIGO from a positive to negative Dix-Hallpike maneuver.
Benign paroxysmal positional vertigo is caused by cal- However, the review20 noted that no long-term assess-
cium debris in the semicircular canals (canalithiasis), ment was performed in either RCT18,19 on the use of the
usually the posterior canal. Medications generally are Epley maneuver. A study16 of 54 patients with benign
not recommended for the treatment of this condition. paroxysmal positional vertigo found that the modified
The vertigo improves with head rotation maneuvers Epley maneuver was effective in resolving vertigo symp-
that displace free-moving calcium deposits back to the toms after one week of treatment. This study, however,
vestibule. Maneuvers include the canalith repositioning has been criticized for inadequate randomization and
procedure or Epley maneuver15 and the modified Epley lack of blinding of outcome assessors (patient self-report
maneuver16 (Figure 2). The modified Epley maneuver of symptoms).20
can be performed at home. One study21 on the long-term effects of canalith repo-
Patients may need to remain upright for 24 hours sitioning procedures in patients with benign paroxysmal
after canalith repositioning to prevent calcium deposits positional vertigo reported a recurrence rate of about
from returning to the semicircular canals, although this 15 percent per year. Another study22 reported recur-

1118 American Family Physician www.aafp.org/afp Volume 71, Number 6 ◆ March 15, 2005
Vertigo

45°

90°

A. D.

ILLUSTRATIONS BY MARCIA HARTSOCK


B. E.
Figure 2. Epley maneuver. The patient sits on the
examination table, with eyes open and head turned
45 degrees to the right (A). The physician supports the
90° patient’s head as the patient lies back quickly from a
sitting to supine position, ending with the head hang-
ing 20 degrees off the end of the examination table
(B). The physician turns the patient’s head 90 degrees
to the left side. The patient remains in this position
for 30 seconds (C). The physician turns the patient’s
head an additional 90 degrees to the left while the
patient rotates his or her body 90 degrees in the same
direction. The patient remains in this position for 30
seconds (D). The patient sits up on the left side of the
examination table. (E) The procedure may be repeated
on either side until the patient experiences relief of
C. symptoms.

rence rates of 20 percent at 20 months and 37 percent at ally lasts a few days and resolves within several weeks.
60 months. Many cases of vestibular neuronitis or labyrinthitis are
attributed to self-limited viral infections,7 although spe-
VESTIBULAR NEURONITIS AND LABYRINTHITIS cific proof of a viral etiology rarely is identified.1
Acute inflammation of the vestibular nerve is a common Treatment focuses on symptom relief using vestibular
cause of acute, prolonged vertigo. Associated hearing suppressant medications,6-8 followed by vestibular exer-
loss occurs if the labyrinth is involved. The vertigo usu- cises.14 Vestibular compensation occurs more rapidly and

March 15, 2005 ◆ Volume 71, Number 6 www.aafp.org/afp American Family Physician 1119
more completely if the patient begins twice-daily vestib- Treatment of transient ischemic attack and stroke
ular rehabilitation exercises as soon as tolerated after the includes preventing future events through blood pres-
acute vertigo has been alleviated with medications.7,11 sure control, cholesterol-level lowering, smoking ces-
sation, inhibition of platelet function (e.g., aspirin,
MÉNIÈRE’S DISEASE clopidogrel [Plavix], aspirin-dipyridamole [Aggrenox])
Ménière’s disease (or endolymphatic hydrops) presents and, possibly, anticoagulation (warfarin [Coumadin]).
with vertigo, tinnitus (low tone, roaring, or blowing Acute vertigo caused by a cerebellar or brainstem
quality), fluctuating low-frequency sensorineural hear- stroke is treated with vestibular suppressant medication
ing loss, and a sense of fullness in the ear. In this disor- and minimal head movement for the first day. As soon
der, impaired endolymphatic filtration and excretion in as tolerated, medication should be tapered, and vestibu-
the inner ear leads to distention of the endolymphatic lar rehabilitation exercises should be initiated.8,10
compartment. Placement of vertebrobasilar stents may be considered
Treatment lowers endolymphatic pressure. Although in a patient with symptomatic critical vertebral artery
a low-salt diet (less than 1 to 2 g of salt per day) and stenosis that is refractory to medical management.27
diuretics (most commonly the combination of hydro- Rarely, infarction or hemorrhage in the cerebellum or
chlorothiazide and triamterene [Dyazide]) often reduce brainstem may present with acute vertigo as the only
the vertigo, these measures are less effective in treat- neurologic symptom.28 Given the risk of brainstem com-
ing hearing loss and tinnitus.23,24 Note, however, that pression with a large cerebellar stroke, neurosurgical
the authors of a systematic review25 of treatments for decompression may be indicated.
Ménière’s disease criticized the statistical analysis of the
MIGRAINE HEADACHES
frequency of vertigo episodes in one of the studies.23
In rare cases, surgical intervention, such as decompres- Epidemiologic evidence shows a strong association
sion with an endolymphatic shunt or cochleosacculotomy, between vertigo and migraine.29 Diagnostic criteria have
may be required when Ménière’s disease is resistant to been proposed to provide a more specific definition of
treatment with diet and diuretics. Ablation of the vestibu- vertiginous migraine.29 Diagnostic accuracy is impor-
lar hair cells with intratympanic injection of gentamicin tant because vertiginous migraine may respond better to
also may be effective.26 Surgery usually is reserved for migraine treatments than to other interventions.
patients with severe, refractory Ménière’s disease. One retrospective review30 found that migraine treat-
ments were effective in about 90 percent of patients
VASCULAR ISCHEMIA with migraine-associated vertigo. Treatments included
The sudden onset of vertigo in a patient with additional dietary changes (i.e., reduction or elimination of aspar-
neurologic symptoms (e.g., diplopia, dysarthria, dyspha- tame, chocolate, caffeine, or alcohol), lifestyle changes
gia, ataxia, weakness) suggests the presence of vascular (i.e., exercise, stress reduction, improvements in sleep
ischemia. patterns), vestibular rehabilitation exercises, and medi-
cations (e.g., benzodiazepines, tricyclic antidepressants,
beta blockers, selective serotonin reuptake inhibitors
The Authors [SSRIs], calcium channel blockers, antiemetics).
RANDY SWARTZ, M.D., is voluntary associate clinical professor in Another retrospective chart review31 demonstrated
the Department of Family and Preventive Medicine at the University that stepwise treatment of migraine-associated dizzi-
of California, San Diego, School of Medicine, La Jolla, Calif., and
assistant program director at the Scripps Family Practice Residency
ness (vertigo or dysequilibrium) resulted in complete or
Program, Chula Vista, Calif. Dr. Swartz graduated from the University dramatic reduction of symptoms in 58 of 81 patients (72
of Texas–Houston Medical School and completed residencies in percent). The stepwise treatment consisted of initiating
family practice and psychiatry at the Harbor–UCLA (University of dietary changes, then adding nortriptyline (Pamelor)
California, Los Angeles) Medical Center, Torrance, Calif. if needed, then adding atenolol or a calcium channel
PAXTON LONGWELL, M.D., is a neurologist in private practice in blocker if needed and, finally, consultation with a neu-
Corpus Christi, Tex. He graduated from the University of Texas– rologist if needed.
Houston Medical School and completed a residency in neurology A survey32 of 53 patients with migraine at a univer-
at Harbor–UCLA Medical Center. sity-based headache clinic found that the efficacy of
Address correspondence to Randy Swartz, M.D., 450 Fourth Ave.,
medications in treating migraine-associated dizziness
Suite 201, Chula Vista, CA 91910 (e-mail: swartz.john2@scrippshealth. was directly correlated with their ability to alleviate
org). Reprints are not available from the authors. migraines. This correlation was strongest in patients

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Vertigo

with vertigo who were receiving migraine-abortive med- sensory systems. Motion sickness occurs while riding
ications (most significantly, sumatriptan [Imitrex]). in a car, boat, or airplane if the vestibular and somato-
sensory systems sense movement, but the visual system
PSYCHIATRIC DISORDERS does not.
Vertigo commonly is associated with anxiety disorders On the first sensation of motion sickness, efforts
(e.g., panic disorder, generalized anxiety disorder) and, should be made to bring vestibular, visual, and somato-
less frequently, depression.33,34 Hyperventilation usu- sensory input back in congruence. For example, a person
ally occurs and can result in hypocapnia with reversible on a boat who starts to feel seasick should immediately
cerebral vasoconstriction. Hyperventilation and hypo- watch the horizon. Seasickness can be prevented by
capnia may be accompanied by dyspnea, chest pain, applying a scopolamine patch (Transderm-Scop) behind
palpitations, or paresthesias. one ear at least four hours before boating.8,36
Subclinical vestibular dysfunction has been measured
The authors indicate that they do not have any conflicts of interest.
in patients with anxiety disorders or depression, most Sources of funding: none reported.
commonly panic disorder with moderate to severe ago-
Members of various family medicine departments develop articles for
raphobia.33 Conversely, classic vertigo resulting from “Practical Therapeutics.” This article is one in a series coordinated by
more ostensible vestibular pathology usually induces the Department of Family Medicine and Preventive Medicine at the
severe anxiety symptoms and thus can be hard to distin- University of California, San Diego, School of Medicine. Guest editor of
guish from a primary anxiety disorder. the series is Tyson Ikeda, M.D.
Vestibular suppressants and benzodiazepines most
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1122 American Family Physician www.aafp.org/afp Volume 71, Number 6 ◆ March 15, 2005